From the Guidelines
The incidence rate of marginal ulcers after Roux-en-Y gastric bypass surgery ranges from 0.6 to 16%. These ulcers typically develop at the anastomosis between the gastric pouch and jejunum, often within the first year after surgery but can occur at any time 1. Risk factors include smoking, NSAID use, immunosuppression, and pre-operative non-steroidal anti-inflammatory drugs use, which were significantly more likely to develop a marginal ulcer requiring surgical revision 1. Patients may experience symptoms such as epigastric pain, nausea, vomiting, bleeding, or dysphagia, though some remain asymptomatic.
Prevention and Treatment
Prevention strategies include smoking cessation, avoiding NSAIDs, and prophylactic proton pump inhibitor (PPI) therapy for 3-6 months postoperatively 1. Treatment typically involves PPI therapy for 6-8 weeks, elimination of risk factors, and in severe or refractory cases, surgical revision may be necessary 1. The development of marginal ulcers is thought to be related to acid exposure at the anastomotic site, ischemia, tension at the anastomosis, or foreign material such as sutures or staples.
Key Points
- The incidence of marginal ulcers ranges from 0.6 to 16% 1
- Risk factors include smoking, NSAID use, immunosuppression, and pre-operative non-steroidal anti-inflammatory drugs use 1
- Prevention strategies include smoking cessation, avoiding NSAIDs, and prophylactic PPI therapy for 3-6 months postoperatively 1
- Treatment typically involves PPI therapy for 6-8 weeks, elimination of risk factors, and in severe or refractory cases, surgical revision may be necessary 1
From the Research
Incidence Rate of Marginal Ulcers after Roux-en-Y Gastric Bypass
- The incidence rate of marginal ulcers after Roux-en-Y gastric bypass varies widely, with reported rates ranging from 0.6% to 25% 2.
- A systematic review of 41 studies with a total of 16,987 patients found that 787 (4.6%) developed marginal ulcers 2.
- Another study found that the incidence of marginal ulcers was 2.3% in a total of 2,535 patients who underwent laparoscopic Roux-en-Y gastric bypass 3.
- A study of 350 patients who underwent LRYGB found that 23 patients (6.6%) developed a symptomatic marginal ulcer 4.
Risk Factors for Marginal Ulcers
- Smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size are associated with the formation of marginal ulcers 5, 2, 6.
- Diabetes, smoking, and long gastric pouches were significant risk factors for marginal ulcer formation, suggesting increased acid exposure and mucosal ischemia are both involved in marginal ulcer pathogenesis 6.
- The use of corticosteroids and NSAIDs was also significantly associated with the development of marginal ulcers 4.
Management and Treatment Outcomes
- Most cases of marginal ulcers are adequately treated with proton pump inhibitors, and sometimes reoperation is required 2, 3.
- A significant portion of patients may require surgical treatment, including oversewing of the ulcer or revision of the anastomosis 3.
- Conservative management is possible in most patients, with only a small percentage requiring surgery 4.